The Rh system is one of the most important and complex blood group systems because of the large number of antigens and the serious complications for the fetus of a woman sensitized by transfusion or pregnancy. Major advances in our understanding of the Rh system have occurred with the cloning of the genes and with functional evidence that the Rh blood group proteins belong to an ancient family of membrane proteins involved in ammonia transport. The arrangement and configuration of the genes at the RH locus promotes genetic exchange, generating new antigens. Importantly, RH genetic testing can now be applied to clinical transfusion medicine and prenatal practice. This includes testing for RHD zygosity, confirmation or resolution of D antigen status, and detection of altered RHD and RHCE genes in individuals at risk for producing antibodies to high-incidence Rh antigens, particularly sickle cell disease (SCD) patients. The Rh proteins form a core complex that is critical to the structure of the erythrocyte membrane, and they may play a physiologic role in the sequestration of blood ammonia. The Rh family of proteins now includes non-erythroid homologs present in many other tissues, and comparative genomics reveal Rh homologs in all domains of life.